alzheimer’s disease/dementia care challenges...dementia program or environment, such as a memory...

Assisted Living Education 1

Alzheimer’s Disease/Dementia Care

Challenges6 hour CEU/CE Course


Objectives

The main topics that will be covered include,but are not limited to:

Assessing your residents Providing care to the residents Managing behaviors Making eating a pleasurable experience


This Course Material has been copyrighted © 2009 byAssisted Living Education

All rights reserved. No part of this coursematerial/content may be reproduced or utilized in anyform, by any means, electronic or mechanical, includingphotocopying, recording, emailing, or any informationstorage and retrieval system, without permission inwriting from Assisted Living Education.

Assisted Living Education has attempted to offer usefulinformation and assessment tools that have beenaccepted and used by professionals within this industry,including the California Department of Social Services.Nevertheless, changes in health/medical care and healthcare regulations may change the application of sometechniques and perceptions in this course material.Assisted Living Education thereby disclaims any liabilityfor loss, injury or damage incurred as a consequence,either directly or indirectly, from the use and applicationof any of the contents of this course material.


Facts and statistics*As many as 5.4 million people in the United

States are living with Alzheimer’s and there aremore than 35 million people around the world withAlzheimer’s or other types of dementia.

Approximately 200,000 age less than 65 years ofage.

Every 68 seconds, someone developsAlzheimer’s.

Alzheimer's is the sixth-leading cause of deathand fifth leading cause of death in Americans age65+ years

*According to the 2012 Alzheimer’s Disease Facts and Figures produced by the Alzheimer’s Association.

Facts and statistics*

By 2050, there is expected to be one newcase of AD every 33 seconds, or nearly amillion new cases per year, and ADprevalence is projected to be 11 million to 16million.



Facts and statistics*

The direct and indirect costs of Alzheimer'sand other dementias to Medicare, Medicaid andbusinesses amount to more than $200 billionlast year.

Barring a medical breakthrough, the WorldAlzheimer Report projects dementia will nearlydouble every 20 years. By 2050, it will affectnearly 115.4 million people worldwide!

*According to the 2012 Alzheimer’s Disease Facts and Figures produced by the Alzheimer’s Association and the World Alzheimer Report, 2012


Let’s test your knowledge…..

Q: It’s a good idea to rearrange yourresident’s dressers and drawersbecause it helps stimulate theirbrain and learn.

a. Trueb. False



Q: It’s a good idea to rearrange yourresident’s dressers and drawersbecause it helps stimulate theirbrain and learn.

a. Trueb. False


Let’s test your knowledge…..Q: During an episode of agitation, choose three

things you can do that might help:

a. argueb. offer choices between two optionsc. restraind. say “I’m sorry you’re upset”e. make calm, positive statementsf. enter into “their world”



Q: When a resident exhibits a difficultbehavior, the first thing you should dois look for the:

a. nurseb. family memberc. reasond. supervisor



Q: Residents with AD never hidesomething in the same place twice.

a. Trueb. False



Q: When feeding a resident with AD, it’simportant to have all of their food,including dessert, in front of them atone time.

a. Trueb. False


REGULATIONS REVIEW

DSS Regulations

Per the Evaluator’s Manual, Section 87705:

The licensee must meet the requirements inTitle 22, Section 87705, Care of Personswith Dementia, for any resident diagnosedby a physician as having dementia,regardless of whether it is a primary orsecondary diagnosis.


DSS Regulations (cont’d)In addition to the requirements in Title 22, Section87705, licensees who advertise, promote orotherwise hold themselves out as providing specialcare, programming, and/or environments forresidents with dementia or related disorders shallalso meet the specified requirements in Title 22,Section 87706 (Advertising Dementia SpecialCare, Programming, and Environments) andSection 87707 (Training Requirements ifAdvertising Dementia Special Care, Programming,and Environments).


DSS Regulations (cont’d) A licensee does not have to have a special

dementia program or environment, such as amemory unit or dementia wing, in order to accept orretain residents diagnosed with dementia.

Some facilities do not have special units, andpersons diagnosed with dementia live with otherresidents in the general community.

The licensee must be able to meet the resident’sneeds and comply with regulatory requirementswhen caring for persons with dementia.


DSS Regulations (cont’d)

Meeting residents’ needs may include:

annual appraisals; physical plant enhancements like

delayed egress; and locked perimeters and auditory alarms

if wandering or other behaviors areexhibited.



Emergency Disaster Plan:

You must address how you will safelyevacuate and care for your dementiaresidents.

This plan is particularly important in facilitiesusing delayed egress devices, lockedperimeter fence gates or locked exterior doors.



Training!Reassessments!Staffing!

If a resident is awake during night time hours,appropriate activities shall be available to meet thespecific needs of the resident.

Safety!Residents who are determined to be unable to managetheir own personal grooming/hygiene items should nothave access to the grooming items of other residents.



Staff Training (cont’d)Dementia Care Facilities:

Direct care staff training requirements:1. 6 hours of orientation specific to care of

residents with dementia within first 4 weeksof employment.

2. Up to 2 of these hours can include mentoringand hands-on training from a qualified staffmember.

3. 8 hours of in-service training within 12months of employment and each additional12-month period.


Staff Training (cont’d)Dementia Care Facilities:

Direct care staff training requirements:Minimum 2 of the following training topics to be coveredannually, and all topics covered within a 3-year period:

1. Effects of medication on the behavior of residents with dementia;

2. Common problems, such as wandering;3. Positive therapeutic interventions and

activities4. Communication skills5. Promoting resident dignity, privacy, etc.6. End of life issues, hospice.


ASSESSING YOUR

RESIDENTS


AssessmentsWhat should be part of an appraisal?

1. Will this resident fit in with your otherresidents?

2. Do they have any prohibited or restrictedcondition?

3. Do they have a modified diet or other needthat I can meet?

4. Can they transfer from the bed to theirwheelchair? Can they walk?

5. Do they have a history of wandering?


Assessments (cont’d)What should be part of an appraisal?

6. Do I have precautions in place if they DOwander?

7. Do I have a realistic elopement plan andenough staff?

8. Do you have a non-amb room/apartmentavailable?

9. Do you have 24-hour awake staff?


Assessments (cont’d)

If you are lucky enough to assess themat their house, check for:

Smells Empty alcohol bottles Hoarding issues Medication bottles

Assessments (cont’d)

Tools to use:

Interview all persons involved in theircare

Personal interview of the prospectiveresident

Physician’s Report Preplacement Appraisal


Assessments – Questions to Ask

1. Does the prospective residentunderstand that placement is underconsideration?

2. Is this placement related to a crisis ornear crisis?

3. Is this placement perceived by theprospective resident as temporary orpermanent?



4. Is this the first placement outside of thehome for the prospective resident?

5. Will the prospective resident be able totour the Community prior toplacement?

6. Is the family involved, and what familyis involved, in the placement?



7. Does the family have a clear vision ofexpected care?

8. Is the family united on the placementdecision?

9. What are some of the motivatingfactors prompting placement?

10.Has the family explored other optionsof care (i.e., in-home)?



11.Is the family ready to relinquish care toa facility?

12.If the placement is in a semi-privateroom, has the resident ever shared aroom?

13.Is this roommate a good fit?14.Is there a pet involved?



15.Does the senior/family understand andagree to the House Rules?

16.Have they been told about restrictedand prohibited conditions?

17.How does the family describe theprospective resident’s medicalproblems, other than the cognitiveimpairment?



18.Does the resident require a specialdiet? Can you accommodate it?

19.How often does the resident usuallysee their physician? How will they getthere?

20.What disturbs the resident most aboutthe dementia?

21.What disturbs the family the most?Assisted Living Education 36


22.Explain a typical day for the senior(i.e., hobbies, waking and eating times)

23.What common phrases or words doesthe resident use for the followingactivities?

• Using the toilet• Bowel movement• Urination• Common adjective when something is great



PROVIDING CARE FOR YOUR

RESIDENTS


CaregivingImagine traveling to aforeign land where you:

do not speak thelanguage;

other people do notunderstand what you aresaying to them; and

do not understand whatpeople are saying to you!


Caregiving (cont’d)

How would you feel?

This might be how a resident with AD feels!


General tips for assisting with ADL’s


Important Keys

1. Keep a routine.2. Don’t rush the resident.3. Encourage independence.4. Maintain the resident’s

dignity.5. Be flexible.6. Be patient.7. Have a sense of humor.


Caregiving (cont’d)Communicating with the residents:

1. Yes and no questions.2. Simple statements with short words and

sentences.3. Repeat commands, if necessary.4. Speak slowly and in a low voice.5. Avoid slang (“jump” into the bath)6. Step by step directions.7. Get rid of distracting background noises.



Encourage independence:

Encourage the resident to button uptheir own shirt;

Offer 2 choices when possible; and Ask for their assistance when providing

care



Promote the individuality of each person:

Offer them their favorite food or snack; Find out about their past likes and dislikes

and incorporate them into their daily routine; Provide care for them when they like it rather

when you like it; and Invite them to help you in a task they like to

do, like setting the table or arranging flowers.



Maintaining the resident’s dignity:

Call them by the name they want,never sweetie, honey or dear;

Never talk about the resident in thirdperson or when the resident is nearyou; and

Maintain their privacy when helpingthem with ADL’s.



When you are caring for AD residents…

any small gesture on your part canreally brighten a resident’s day, such asa compliment or a hug!

remember your non-verbal gestures. do things WITH the residents, not FOR.


TasksIt’s important to break tasks down into easier, smaller steps.

Step Description Example

1 Present the step in a way that matches the resident’s abilities.

Mrs. Smith can brush her teeth by herself once I get her started.

2 Demonstrate the step. Use gestures to show her how to brush her teeth.

3 Help begin the step. Put toothpaste on the toothbrush while she holds it, then bring toothbrush to her mouth.

4 Give the resident time to finish each step.

Give her time to finish.

5 Praise the resident for completing each step.

Tell her how great she’s doing.

6 Repeat steps 1-5 if needed.


Completing Tasks

Sometimes slower isbetter; when you rushthe resident, they mayget nervous andagitated. Residentsneed time to processyour requests. Workat their pace.

BATHING



Bathing the AD Resident

For some residents, this may be a frightening and confusing experience. There are ways to make this experience easier and more enjoyable for the resident.


General bathing suggestions Maintain a routine, same time and if possible, same

caregiver. Find out what type of bath/shower routine the resident

used to have: In the morning or evening? Bath or shower? Warm vs. hot water?

Do not ask if the resident wants a bath. Try to use the resident’s preferred shampoo/ soap. Maintain the resident’s dignity and privacy at all times. Be sensitive to the fact that it is not normal to take a bath

with another person.


ResistanceIssue: Refusing to take a bath

Possible causes:o Embarrassmento Lack of privacyo Inappropriate water and/or air temperatureo Lack of routineo Mistrust of caregivero Caregiver approach (too aggressive)o Fear of running water, depth of watero Too much explanation/preparationo Being rushed


ResistanceIssue: Will not take off clothing

Possible causes:

o Room temperature too coldo Privacy issueso Being rushedo Not liking the caregivero Forgot how to


ResistanceIssue: Thinks already bathed

Possible causes:

o Lack of routineo Time of dayo Different caregivero Unable to perceive the need for a bath

(poor sense of smell, vision)

DRESSING



Helping the resident dress Lay out the resident’s clothing. Don’t rush them – try to let them do

as much as they can. Ensure privacy. Let them choose the clothing, if

appropriate. Choose items that fit well and that

aren’t uncomfortable. Ensure that they are wearing proper

footwear. Label drawers and closets with items

enclosed.


ResistanceIssue: Dressing

Issue/concern:

o Layering of clothingo Disrobingo Wrong seasonal clothingo Refusing to remove clotheso Mismatchingo Wearing clothing inside out or backwardso Wearing the same clothes every dayo Unable to dress and undress self


ResistanceIssue: Dressing (cont’d)

Suggestions:

o Do not argue with the resident. Do not forcethem and do not rush them.

o If their choices are not hurting themselves oroffending anyone else, don’t worry about it.

o Look into the possibility of providing clothing thatis easier to get in and out of independently.

o Allow the resident to be as independent as longas possible.

o Label drawers and closets with items enclosed.



Possible causes:o Room temperature too hot/coldo Fear of losing clothes or having clothes stoleno Lack of privacyo Too many clothing choices availableo Inability to make decisionso Clothes too tight, uncomfortableo Needing to go to the bathroomo Lack of routineo Wet or soiled from incontinence



Possible causes:

o Loss of judgment concerning seasono Fear of bathingo Embarrassmento Forgot how to dresso Distracted by other people, activity or noiseso Does not recognize the clothing as their owno Unable to follow directions

GROOMING



Helping the resident with grooming

o Hair – keep hair in an easy-to-care forstyle.

o Washing hair in the sink may be easierthan in the shower.

o Electric razors may be easier than razors.o Teeth – encourage min. 2 x day tooth

brushing. Try cueing.o Women may still want to use lipstick or

powder.o File but do not trim nails only if safe.

ORAL CARE


Oral Care

1. Wear gloves2. Brush the resident’s teeth at least twice a

day, or as needed, with a soft toothbrush3. Be on the look out for loose teeth,

bleeding gums, sores4. Dentures must be removed and cleaned

at night or when desired5. Provide privacy


Oral Care (cont’d)

6. Some residents with Alzheimer’s donot swallow well so make sure youclear the resident’s mouth of anyremaining food and rinse after everymeal.

7. Find a dentist that could do housecalls, if necessary


TRANSFERRING


Transferring Techniques

1. Invite a Physical Therapist in for stafftraining.

2. Use proper body mechanics.3. Move at the resident’s pace, not yours.4. Using assistive devices, such as gait

belts – make sure staff is properly trained!5. If a resident is a 2 person assist, will you

always have 2 staff on?


INCONTINENCE CARE



Toileting the AD Resident

• Keep bathroom doors openwhen not in use to cue resident.

• Keep the resident on aschedule.

• Look for cues that the residentneeds to go to the bathroom.

• Limit caffeine.• Make sure the resident’s

clothing is comfortable andeasy to manage.


Issue/concern:Having “accidents”

Possible causes:

o Unable to recognize sensationo Can’t find the bathroomo Clothes too difficult to removeo Lack of routineo Too much caffeine in dieto Visual problemso Chronic illness (prostate problems)o Unfamiliar caregiver causing anxiety


Issue/concern:Going to the bathroom in inappropriate places

Possible causes:

o Can’t get to the bathroom in timeo Can’t find the bathroomo Visual issueso Poor lightingo Shower chairs feel like a toileto Running water may trigger urinationo Not on a toileting routine


Maintaining the Resident’s Dignity

Close the door when the resident isbathing or toileting.

Do not talk about the resident in front ofother residents.

Do not criticize the resident if they’ve hadan accident.

Let them do as much as possible forthemselves.


BEHAVIORS


Behavior

First and foremost, everybehavior has a reason. Itmay not be apparent, but itis important to determinewhat is causing thebehavior.

Please, do not label theresidents as difficult, etc.They are not doing it onpurpose.

Why?

New surroundings or a change in currentsurroundings (i.e., rearranging theirfurniture)

Paging system (the voice from nowhere!) New or unfamiliar caregivers Separation from loved ones Colors and patterns on walls and furniture Isolation Too much activity – sensory overload!!!


Why? Lighting (too bright, shadows) TV or radio left on all day long “White” noise (i.e., refrigerator) Room temperature (too hot, removes

clothes; too cold, gets into bed withanother resident)

Shiny floors “Bugs” on the walls Approach of the caregiver



Aggressive and Agitated BehaviorCommon reasons:

Unmet needs such as hunger, or having togo to the bathroom

PainLonelinessFrustrationRejectionA perceived threatOver-stimulation


Agitated Behavior

Frowning Speaking loudly Rattling door knobs Acting hostile Shaking his/her fists Speaking quickly Being unable to relax

Pacing Waving his/her arms Wringing hands Backing away from

others Elopement Refusing to do a task


Aggressive BehaviorPhysical

o Bitingo Hittingo Kickingo Punchingo Pushingo Slapping

Verbal

o Cursingo Threateningo Screamingo Name-calling

Behavior History

Ask the family if the resident ever exhibited the following behaviors:

Crying Cheeking FoodPacing HoardingAnorexia Rummaging


Behavior History (cont’d)

Also ask the family:

When the resident refuses or does notwish to allow care, what approach hasbeen most successful? Least successful?

Does the resident traditionally had aproblem with certain caregivers (i.e.,male)?



BehaviorsWhat do I do if a resident is being aggressive?

1. Back off.2. Is the resident acting this way because they’re

in pain? If so, deal with it.3. Do not take the resident’s anger personally.4. Do not argue with the resident.5. Talk in a soft, low voice; do not yell back.6. Reduce stimulation (TV, etc.).7. Try to redirect the resident, if possible.


8. If the person is a biter, try to wear paddedclothing.

9. If a resident throws things, give them soft itemsto throw.

10. If the resident throws eating utensils, try givingthem finger food.

11. If a resident self-injures, try putting gloves onthem or dress them in clothing that covers theirskin.

12. Place your body in a safe position if yourresident hits or kicks – do not stand directly infront of them.


Hallucinations, Delusions and Paranoia

Hallucinations – seeing, hearing orsmelling things that aren’t really there.

Delusions – an illusion that the residenthas that is inconsistent with theirknowledge or beliefs.

Paranoia – Suspicious thinking


Coping with these behaviorsDon’t use a paging system!Keep familiar objects around.Change the environment (their room) as little as

possible.Try to clean their apartment when they’re not

there.Do not try to argue or reason with the resident.Try to find a caregiver that the resident is

comfortable with and have that caregiver workwith them.


Hiding and blaming

Resident hidessomething

Resident can’tremember where

they hid it

Resident blamessomeone

Help them“find” it


Hiding and blaming (cont’d)

1. You probably can’t ask the residentwhere they hid the object.

2. Keep their apartment clean and orderly.3. Limit the number of hiding places by

locking some closets or rooms.4. Take away valuable items – give to

appropriate family member.5. Make small, easily lost items more visible

(i.e., large key ring)



6. Keep a spare set of keys, hearing aids,eyeglasses, if possible.

7. Check wastebaskets before emptyingthem.

8. Check under mattresses.9. Check in shoes.10. Ask the family where they used to hide

gifts, etc.11. Possibly use a audible key finder, etc.



12. Keep the resident’s closet open so theycan see things in plain view – this maydecrease their need to “search.”

13. Don’t leave things lying around – putthem away.

14. Give them a “rummage” drawer.15. You can try putting a sign that says “NO”

on drawers, etc.


HoardingIt is believed that dementia residents who grewup in the Great Depression hide and hoarditems.

Other reasons might be boredom, a history ofcollecting things, or a need to “hold on” tosomething to “keep it safe.”

When cleaning the resident’s room, you maywant to return the items at that time.


Rummaging

When residents “lose” things, they oftenrummage through other residents’ rooms. Theymay think that it is their room if the rooms looksimilar.

Lock doors and closets, if necessary.

You can also install child-proof locks on drawers.

Label items, if appropriate.


Rummaging (cont’d)

If rummaging isn’thurting anyone, itmight be alright toignore it. Just beaware of regular“hiding” and“retrieving” spots.


Repetition

This might be one of the hardest thingscaregivers have to deal with – theconstant, never-ending, repetitivequestions. The resident is unable toremember that they asked thequestion…..so they’ll ask it again. Try toredirect the resident, or pay more attentionto them. Remember – they’re not doingthis to drive you crazy!

Biting

Try giving the resident gum or candy, if it’ssafe.

Provide textures and touch for stimulation Place a towel over the staff member’s

shoulder to prevent biting during transfer. Have a staff member wear heavy jackets

during activities such as transfers.


Pinching, Grabbing and Scratching

Determine the cause of the grabbing (forexample, fear of falling or desire to keepsomeone with the person); try to meet theneed calmly.

Give the person something soft to hold onto (a rolled up washcloth, stuffed animal,etc.)

Keep the resident’s fingernails short.


Throwing

Determine what throwing may have for theresident (i.e., anger, part of a sport orrecreation).

Play catch with a safe foam ball or beachball.

If utensils or plates are thrown atmealtimes, use finger foods.


Hitting

Be sure that your staff know how toprevent aggression and how to managepotentially dangerous situations.

Use sudden distraction, like loud calling ofthe resident’s name or clapping, when theperson is about to strike out.

Separate individuals who bring outnegative behaviors in each other.


Hitting (cont’d)

Try one-on-one activities if the individualdoes poorly in a group.

Remove the person from high-activityareas.

Try playing calming music with a taperecorder or personal headset.

Teach your staff how to properly approachthe residents.


Yelling

Be sure that the resident has beenadequately evaluated or treated for pain.Yelling may be their only way to let youknow they’re in pain!

Move the resident to a quieter place. Ask why the resident is yelling. Are they being ignored by the staff?

Threatened?Assisted Living Education 100


Wandering

Many AD residents will want to wander. It’s extremelyimportant that the resident does not wander outside unattended.


Issue – why is the resident wandering?

Possible causes:

o The resident wants to go “home.”o The resident is looking for something or

someone.o The resident is bored, hungry, thirsty, etc.o Cueing toward door, open door.o Agitated due to physical pain, illness.o They have to go to work, school, etc.


Wandering suggestions

Have an elopement plan and train staff! Develop safe wandering paths inside and

outside the facility. Put items that remind them to go outside out of

sight (coats, umbrellas) Minimize staff, family, etc. comings and goings. Take the resident for regular walks. Make the doors as “unnoticeable” as possible. Keep the resident busy in activities.


Redirecting a resident that wants to go “home”

Make the resident’s room as familiar as you canwith their familiar furniture, pictures, bedding,knick-knacks.

Keep the surroundings as calm and familiar aspossible.

Maintain a routine. Get the resident involved in an activity. Ask a family member to visit or call. Distract the resident with food, music. Take the resident for a walk.


Redirecting a resident that wants to go “home” (cont’d)

Step Description Example1 Join the resident as they

wander outside, making sureyou don’t go too far from thefacility.

Caregiver: “Mrs. Smith, do youmind if I go with you?”

Mrs. Smith: “All right, but I’m in ahurry.”

2 Ask the resident where theyare going.

Caregiver: “Where are you headedto, Mrs. Smith?”

Mrs. Smith: “I’ve got to catch thetrain to Irvine – don’t try to stopme!”



Step Description Example3 Begin a conversation with the

resident.Caregiver: “So, Mrs. Smith, do youhave family in Irvine?

Mrs. Smith: “Yes, my mother-in-lawlives there and I have to go seeher.”

Caregiver: “Really? What’s shelike?”

4 Change the topic ofconversation and startredirecting the resident.

Caregiver: “Mrs. Smith, I thinkthey’re starting bingo right nowand you love bingo, don’t you?”



Step Description Example5 Redirect the resident back

into the facility.Caregiver: “Mrs. Smith, let’s walkback in to the facility – bingo isstarting now. I will sit and play, too!Doesn’t that sound fun?”

6 Resistance. Repeat steps 3-5.


Wandering

Safe wandering benefits:

increased appetiteactivityexerciseimproved circulationimproved mobility


What is your facility’s elopement policy?


Catastrophic Reactions

A resident may get so overwhelmed by atask that they outright refuse to completethe task and become overly upset.

Often, a catastrophic reaction does notlook like a behavior caused by a brainillness – it may look as if the person is justbeing obstinate, critical or overemotional.


Catastrophic Reactions (cont’d)

Often, catastrophic reactions are the firstbehaviors family members will notice –and they will begin to sense thatsomething is wrong with the resident.

First, they must accept that the personwith dementia can’t help this behavior –they are not just stubborness or nastiness.


Catastrophic Reactions (cont’d)The best way to manage a catastrophic reactionis to stop it before it happens. Triggers varyfrom person to person and from one time oranother, but some of the causes could include:

needing to think about several things at once(for example, all the tasks involved inbathing);

trying to do something that the person canno longer manage;

being cared for by someone who is rushed orupset;


Catastrophic Reactions (cont’d) not wanting to appear inadequate or unable

to do things; being hurried; not understanding what they were asked to

do; not understanding what they saw or heard; being tired or hungry; not feeling well; not being able to communicate their needs; feeling frustrated; and being treated like a child.



Avoiding reactions:

1. familiar routines2. familiar faces3. breaking down a task into easy steps –

one at a time4. patience



Let the resident do for him/herself until he/she shows the first signs of frustration, then assist him/her before he/she becomes more upset. Urging them on will usually only upset him/her more.



Gently holding a person’s hand or pattingthem might help calm them down, but theperson may feel that you are restrainingthem and become more upset.

Physically restraining someone often addsto their panic.



o When a resident becomes agitated,immediately stop whatever is upsettingthem and let them relax.

o Do not continue to push them.

o They may become agitated enough tobecome combative.


Sexuality and the AD resident

Yes, this is going to happen.Yes, the family membersmight be upset.

This is a difficult situation –you are responsible for thesafety and security of eachresident, but you don’t want toviolate the resident’s rights.


Sexuality issues

Possible issues:

o Saying “inappropriate” thingso Doing “inappropriate” thingso Touching staff or residentso Undressing


Possible causes:

o Caregiver reminds them of their past o Approach of caregiver misinterpretedo Loneliness, needs affection and attentiono Hot, or clothes are uncomfortableo Brain damage causing poor judgmento Past personality traito Lack of privacyo Needs to go to the bathroom


General suggestions about sexuality

o Do not respond with shock or shame the person.o Provide appropriate affection and attention.o Not all behaviors are sexual in nature – an

“exposer” may need to go to the bathroom or theresident who climbs into bed with anotherresident may be cold.

o Distract the resident with food or an activity.o Alert the caregivers about what things might

trigger this behavior.o Discuss this with the family members.


General suggestions about sexuality (cont’d)

o Resident may be undressing themselvesbecause they’re too hot or uncomfortable.

o They may touch themselves because theyhave to go to the bathroom, they’ve hadan accident, they have a UTI and are inpain, or they have a rash.

o Residents may touch other people to beflirtatious.


Sundowning

As many as 20% of residentswith AD are more agitated,confused or restless in thelate afternoon or earlyevening. The cause isn'tknown, but factors that mayaggravate late-day confusioninclude:

FatigueLow lighting Increased shadows

SundowningPer the Alzheimer’s Association, factors that maycontribute to sundowning and sleep disturbances include:

End-of-day exhaustion (both mental and physical)

An upset in the "internal body clock," causing a biologicalmix-up between day and night

Reduced lighting and increased shadows causingpeople with Alzheimer's to misinterpret what they see,and become confused and afraid


SundowningPer the Alzheimer’s Association, factors that maycontribute to sundowning and sleep disturbances include:

Reactions to nonverbal cues of frustration fromcaregivers who are exhausted from their day

Disorientation due to the inability to separate dreamsfrom reality when sleeping

Less need for sleep, which is common among olderadults



Sundowning Issues

Plan for activities and exposure to light duringthe day to encourage nighttime sleepiness.

Leave lights on and shut out the darkness byclosing blinds or shades.

Encourage naps during this time.Shift changes – keep distractions to a

minimum. Residents may want to leave withthem to “check on their children.”

Keep the resident well hydrated throughoutthe day.


Sundowning IssuesMaintain a schedule.Avoid stimulants and big dinners.Keep a night light on to reduce agitation that

occurs when surroundings are dark orunfamiliar.

Try to identify triggers (i.e., loud TV)


Sleep Issues

Many people with AD are restless atnight.

They may get up to go to the bathroomand then become lost, confused anddisoriented.

They may see things or hear things thataren’t there.


Sleep Issues (cont’d)Possible solutions:

• Decrease the resident’s napping during the day• Exercise them more frequently• Check their medication• Toileting them right before they go to bed• Installing a nightlight in their room• Make sure their bed and pajamas are comfortable• Check the temperature in the room• Redirect them back to bed when wandering


Sleep Issues (cont’d)

The use of sedatives may lead to:

increased fallsconfusiondizzinessdaytime sleepinessphysical dependence


Non-drug treatments for sleep issues:

Maintain regular times for meals and for going tobed and getting up

Seek morning sunlight exposure Encourage regular daily exercise, but no later than

four hours before bedtime Avoid alcohol, caffeine and nicotine Treat any pain



Non-drug treatments for sleep issues(cont’d): If the person is taking a cholinesterase inhibitor

(i.e.,donepezil) avoid giving the medicine before bed Make sure the bedroom temperature is comfortable Provide nightlights and security objects If the person awakens, discourage staying in bed

while awake; use the bed only for sleep Discourage watching television during periods of

wakefulnessAssisted Living Education 132


ACTIVITIES


Your Residents

It’s very important for you and yourteam to know the history of eachresident. This includes:

• past profession• likes and dislikes• hobbies and interests• socialization needs


Activity Program

o Keep activities between 30-45 minutes o Try to have at least one scheduled activity after dinnero Outdoor time (walks, etc.)o Exercise/physical fitnesso Small group activitieso Birthday and anniversary partieso Gender specific activitieso Support group meetingso Snackso Use of volunteers


Low functioning activities Folding laundry Sorting socks Setting the table Washing dishes Cooking/baking class Chair exercise Stretching Sing-a-long’s Watching TV Listening to music


High functioning activities

Outdoor walks Exercise Current events Reminiscence Creative activities such as painting, poetry,

building things, story-telling Gardening Hallway bowling, kicking the balloon


Activities to Avoid

A. Leaving the TV on all dayB. Playing the radio all dayC. Noisy, confusing activitiesD. Activities that last more than 45 minutesE. Physically demanding activitiesF. Things that require memoryG. Childish activitiesH. Bad news or sad news


CARING FOR THE

CAREGIVER


Caring for the Caregivers

Anyone who has provided care to an ADresident knows it’s hard work – bothphysically and mentally. You may developan emotional attachment to the resident,like a family member. This can lead toadded stress in caring for the resident.

You need to develop a routine of self-care.


Self-Care I eat healthy, balanced meals. I don’t come to work sick. I exercise and get fresh air. I have hobbies. I enjoy music or reading. I know how to deal with stress. I know when to ask for help. I share my feeling when I feel angry, frustrated,

over-whelmed, etc. I have friends and/or family that I can rely on. I participate in all training my company offers.


Making Dining a Positive

ExperienceSpeaker: Pam Cameron


Objectives1. Explain why the dining experience is so

important to the resident’s well-being2. Proper food choices for residents with AD3. Proper food presentation (i.e., one course

at a time)4. Eating tips and techniques5. Meeting resistance6. Hydration and dehydration issues7. Choking risks

Delighting your Customer!

Yes, dining plays a extremely important rolein how happy our residents are.

But do you know how much?

A positive or a negative dining experiencecan affect their physical, social andemotional well-being!



First, let’s brainstorm to determine whatcreates a positive dining experience for ourresidents with AD……



Did your list include:

Serving the resident their preferred foods?An appropriate variety of foods?The appearance and how it was presented?Did the resident enjoy the food?


Licensing Requirements

Regulations state that we must serve theresidents “an appropriate variety of foodsand shall be planned with consideration forcultural and religious background and thefood habits of the residents.”

• What is appropriate for our residents with AD?• How do we find out what they like?


Dining Together

The Social Aspectof Meals

Cultural Considerations


Dining Together (cont’d)

Styles of Service (family style, etc.) The role of our senses

Decreased senses – taste, smell

Balanced diets Limiting saturated fats, sodium and

sweets Managing costs


Dining

So…..what should we feed our residents with AD?



Food Choices for Residents with AD

• Small, “finger foods”• Not too many items on the plate• Peas, small bits of food are hard to scoop up• Rough textured food, like toast, that stimulates

the person’s tongue and encourages chewing• Mashed or pureed fruits or vegetables• Scrambled eggs, puddings, chicken fingers• Sandwiches into quarters• Use bendable straws• Residents with AD love sweets!


Food Choices to AvoidHard candyTaffyHot dogsNutsCrunchy foods like chips or crackersPeanut butterGumGrapes or cherriesThin liquids if given too rapidly


Helping the Resident Eat

Things that might causeproblems with eating:

Not enough light, or glare Noise and distractions Too many choices Unpleasant smells Unappetizing food Anxiety over being rushed


Helping the Resident Eat (Cont’d)

Personal conditions that may disrupt eating:

Mouth discomfort Side effects of medication Inability to recognize hunger Constipation Agitation Forgetting how to eat or use utensils


Eating Tips & Techniques

1. Eating with one or two other people in a quietroom.

2. Restless residents should be encouraged toeat with other residents and have frequentnutritious snacks.

3. Sleepy residents should also be encouraged toeat with other, interactive residents.

1. Do not try to serve a resident that is too sleepy –they may choke.


Eating Tips & Techniques (cont’d)

4. Do not use plastic utensils but you can use aplastic tablecloth or placemats.

5. Use a placemat that is a different color thanthe plate.

6. Avoid glass if the resident has difficulty seeingit.

7. Make sure the resident’s dentures are in inplace and they fit properly.

8. Keep food simple!9. Offer one choice at a time.10. Play soft, relaxing music at mealtime.11. Encourage the serving of “finger foods.”



10. Pay attention to your residents; do notsocialize with other staff during mealtimes.

11. Allow residents to feed themselves as much asthey can.

12. Resident food likes/dislikes13. Pay attention to food temperature.14. NO alcohol!15. Remove condiments (salt, pepper, etc.) from

the table if the resident is confused by them.16. If the resident is confused by too many

silverware choices, only give them one.



Do not have on the table:

items that look like food, but are not(i.e., fake fruit)

salt, pepper, hot sauce, vinegar plants

Food Presentation

Serve meals on colorful dishes withcontrasting colors since Alzheimer'spatients can't always differentiatebetween a piece of white chicken on awhite plate.

Opt for red or green plates where foodbecomes easily visible.


Food Presentation

NO!


Eating Challenges

Someone with Alzheimer's can have moodand behavioral changes that impact on theirability to take a good balanced diet.

They may be highly distractible, talkative,apathetic, anxious, agitated or displaywandering behavior that will all inhibit theirability to eat.



ResistanceIssue: Refusing to eat

Possible causes:

o Unpleasant presentation of foodo Too many choiceso Noise and confusion in dining room, smellso Approach of caregivero Dry mouth from medicationso Pain from dentures or teeth issueso Inability to recognize sensation of hungero Fear of poisoning (distrust of caregiver)

What to try

Give them foods that they like! Try sweet foods, like fruit or applesauce Keep noise and activities to a minimum Check for chewing problems Keep a routine Find that favorite caregiver to assist Encourage physical activity Consult their physician



ResistanceIssue: Eating all the time

Possible causes:

o Short-term memory losso Lack of routineo Burning calories from pacing, agitationo Boredomo Former smoker

What to try

• Feed them more frequently (try 5-6 mealseach day), and smaller amounts at each meal

• Keep a routine• Give them something to drink• Have low calorie snacks available, such as

apples and carrots• Consider whether other activities such as

walks, or increased social contacts may help



ResistanceIssue: Unable to sit still

Possible causes:

o Short attention spano Foods presented in complicated wayo Agitation from confusing environmento Inactivity during non-meal times

What to try

• Give the resident “to-go” foods (small piecesof sandwiches, etc.)

• Make the dining room as inviting as possible• Play their favorite music• Have a caregiver sit with them



ResistanceIssue: Difficulty eating and swallowing

Possible causes:

o Brain damage from the diseaseo Need for cues or modelingo Mouth discomforto Dry mouth from medicationso Throat infectiono Inappropriate sizes/texture/form of food

What to try

• Check medications for side effects• Schedule a dental exam• Offer soft foods or small bites one at a time• Cut food into small pieces or chop/grind• Moisten foods with gravy or sauce• Provide hydration• Serve liquids with a straw• Have a caregiver sit with the resident and cue

themAssisted Living Education 169


ResistanceIssue: Eating inappropriate things

Possible causes:

o Inappropriate things on dining tableo Things that look edible, like wax fruito Smells goodo Poor lightingo Diminishing eyesight

What to try

• Never put inedible items, like pine cones, onthe dining table

• Supervise the residents while eating• Ensure there is adequate lighting• Serve familiar food

NO!



ResistanceIssue: Forgetting they just ate

Possible causes:

o Memory loss from brain damageo Lack of routineo Craving other foods/sweetso An activity cues the person to eato Time change (daylight savings)o Boredomo Confusion other symptoms, like dehydration,

with hunger

What to try

• Maintain a routine• Involve them in an activity• Provide high-calorie foods or large portions

(if they are still hungry)….or• Provide smaller meals more often• Keep them hydrated – offer a beverage



ResistanceIssue: Forgetting that they haven’t eaten

Possible causes:

o Time change (if it’s dark, they must have eaten)

o Change in routineo Constipationo Unable to recognize hungero Actually have been eating/snacking all day


ResistanceIssue: Weight loss, even with eating

Possible causes:

o Pacing/agitationo Inappropriate dieto Physical problem (unable to

absorb nutrients)o Acute illness/disease (cancer)

What to try

• This could indicate a serious illness ordisease – schedule a doctor’s appointment

• If the doctor prescribes a nutritionalsupplement, serve it to the resident asdirected. Do NOT do this without a doctor’sorder.

• Provide higher calorie meals or morefrequent meals



Dehydration

Dehydration is a serious, sometimes fatalcondition.

Dehydration = not enough body fluids andimportant blood salts in the body to carryon normal functions at the best level.

Dehydration occurs with a loss of fluids,not drinking enough water, or acombination of both.


Dehydration (cont’d)

Thirst is the first warning sign that we shoulddrink, but some of our residents can’trecognize that sign.

A healthy adult should drink at least six 8-ounce glasses of water each day.

If urine is pale in color and occurring every2-3 hours, then they’re drinking enoughwater.



Common reasons why people don’t drink enough fluids:

1. not provided to them2. lack of thirst3. don’t like to go to

the bathroom



Try to pay attention to what residents drinkand how much they urinate, especiallyresidents with AD or dementia.

Dehydration can be extremely dangerousin the elder population and must beaddressed immediately.


Dehydration (cont’d)Mild dehydration: Thirst Dry lips and tongue Skin looks dry

Moderate dehydration: Skin not very elastic, may sag and doesn’t

bounce back quickly when lightly pinchedand released

Decreased urine output Sunken eyes


Dehydration (cont’d)Severe dehydration:

small amounts of dark colored urine low blood pressure, dizziness rapid breathing blue lips rapid, weak pulse over 100 (at rest) cold hands or feet confusion, lack of interest shock



Tips to encourage fluid intake:

1. Keep fluids within resident’s reach.2. Offer a variety of fluids to avoid

monotony.3. Offer small amounts often.4. Offer foods with a high water content.5. Serve fluids at proper temperature.


Choking Risks

A resident might not be able todisplay that they are choking.Look for:

Inability to talk Confusion and anxiety Difficulty breathing or noisy

breathing Skin, lips and nails turning blue


Choking Risks (cont’d)

If a resident has trouble swallowing, makesure they are sitting up straight with theirhead slightly forward – never tilted back –when they eat.

Some liquids are much easier to swallowthan others. If your resident is choking on fluids like water,

try a thicker liquid, like apricot or tomato juice.

Challenges with Eating

In the final stages of Alzheimer's diseasemany people having difficulty:

• opening their mouths• chewing food• swallowing



Conclusion

Assisted Living Education thanks you for attending thisConference.

We look forward to seeing you again atanother of our Courses!

alzheimer’s disease/dementia care challenges...dementia program or environment, such as a memory...

Documents